Sunday, 24 July 2011

One day a notebook belonging to Lenny was found in his room. It was full of rambling drunken notes and tirades (“If you find me dead in the morning, it was because Jerry poisoned my Carlsberg.”) But it also contained some more alarming things. One of them was a "hit list" of named people whom he considered his enemies, mainly people connected with the hostel (I was on the list), as well as diagrams and recipes for molotov cocktails and petrol bombs, and much material outlining a universal conspiracy against him involving the IRA and Neo Nazi organisations, which included the belief that these organizations were systematically arranging for his food to be poisoned.

The hostel manager was understandably alarmed at this and wanted him to be expelled immediately. However, the committee was more sanguine. There was something distinctly Adrian Moleish about his ramblings, and we did not take them to constitute serious threats. Instead it was suggested to Lenny that he might feel more comfortable if he had his own accommodation. I helped him to negotiate with the local council, and he was offered a one bedroom flat.

He was delighted with this, but still suspicious. He seemed to manage reasonably well living on his own. He did agree to a community nurse from the CMHT visiting him, as well as a support worker. From time to time he would turn up unannounced at the CMHT and chat to me. Although he appeared to regard me with suspicion, I suppose he also saw me as offering some sort of continuity in his life.

It became increasingly clear from these informal chats with him that, now he was living alone, his paranoid beliefs were being allowed full rein, and were becoming more elaborate and universal in nature. He was convinced that food bought from supermarkets was poisoned or contaminated with noxious substances including the HIV virus. He talked about seeing members of the Ulster Volunteer Force in Charwood Post Office. He said on one occasion he had barely escaped with his life. If he hadn’t left, he knew they would have opened fire on him.

One day, I received a call from the Charwood Environmental Health Dept. They had received a visit from him in which he had given them an assortment of foodstuffs, including cans of lager, tins of food, and some vegetables, with an accompanying letter outlining the contaminants that had been added to them, and asking them to analyse them for him. We also heard that he had been writing to the manufacturers of various products accusing them of selling him contaminated goods.

We eventually managed to persuade Lenny to attend for an outpatient appointment with the CMHT psychiatrist. I sat in on that assessment. He freely talked about his elaborate delusional beliefs relating to paramilitary groups, Nazi’s, and a conspiracy to contaminate the food of the inhabitants of Charwood in order to subject them to mind control. We arranged for his GP to attend (yes, we were planning a MHA assessment). And we detained him under Sec.3.

This admission brought to light the full, and somewhat unsettling, extent of his acting on these persecutory delusions. On admission, he was found to have a knife and a sock full of broken glass in his bag (for defensive purposes). A few days later, his community nurse, who was visiting his flat in order to collect clothes and toiletries for Lenny, found that the cupboard under his kitchen sink was crammed with home made incendiary devices made from glass bottles filled with petrol. The police and the Army Bomb Disposal Squad attended and disposed of them.

Lenny’s diagnosis was changed: his symptoms were undoubtedly entirely consistent with a diagnosis of paranoid schizophrenia. Did we miss this over the years? Did his earlier diagnosis of borderline personality disorder muddy the waters? Quite possibly.

Lenny was prescribed antipsychotic medication and he did appear to improve. After a few months he was discharged back home, subject to S.117.

For a while he appeared much happier and settled. He even seemed more open and friendly. But it did not last. He gradually became depressed and his self care deteriorated. A few months later, he actually asked to be admitted to hospital. On admission, as his depression was treated, his underlying persecutory and paranoid beliefs emerged, as bad as ever. I had to detain him one again under Sec.3.

This time, however, treatment did not appear to result in any significant improvement in his paranoia, if anything, the depth and extent of his paranoid beliefs increased. He was disruptive on the ward, and so suspicious of the staff and food that it was very difficult to get him to eat anything. He remained completely insightless, and made regular attempts to escape from the ward, on one occasion trying to dig an escape tunnel in the occupational therapy vegetable garden.

In view of Lenny’s history of potential dangerousness, his unshakeable delusions and poor response to treatment, Lenny was transferred to a secure unit. He remained there for three years. During that time, my only contact with him was when I visited him to interview him for Tribunal reports, and to attend Tribunals. Whenever I saw him, he was consistently hostile. “Come to stitch me up again, have you, Masked AMHP?” he would say.

He was never discharged by these Tribunals, not because I had “stitched him up”, but because as soon as he was given the opportunity to speak, he would tell the Tribunal all about the plots by the Nazi’s or various Northern Irish paramilitary organisations to kill him. And then they would nod their heads sympathetically, adjourn for a discussion – and then would invariably uphold the detention.

However, over time, and with a change in his antipsychotic medication, his mental state did improve. One day I visited him for a S.117 review meeting, and he greeted me with a smile, shook me warmly by the hand, and enquired politely about how things were going in Charwood. Over a six month period, he had improved to such an extent that in all the years I had known him I had never actually seen him so well. The review concluded that he could be transferred back to an open ward, with an eventual plan of returning to live in Charwood in independent accommodation.

His improvement continued back in Charwood Psychiatric Unit. We started to make plans for his discharge, applying to the local council for housing. We managed to get him a nice flat surprisingly quickly. And he was discharged from Sec.3 and at last came back to live in Charwood.

Lenny was quite different this time. He engaged with support workers, happily accepted his depot injection, and religiously took his oral medication. He took an interest in decorating and furnishing his flat. He always welcomed me warmly whenever I visited him, and we have long and rational conversations. He hardly drank alcohol at all. For eighteen months he actually seemed happy and fulfilled.

Then one morning one of his support workers returned to the CMHT to say that she had been unable to get a response from him. This was not like Lenny. He enjoyed the visits from the support worker. I went out to investigate further. The flat was on the ground floor, so I tried looking in through the windows. His TV was on in the living room but Lenny was not in there. He wasn’t in the kitchen. The curtains were drawn in his bedroom. It was too early for Lenny to have gone out, and he wouldn’t have done knowing his support worker was visiting.

I called the police. They joined me at his house. We contacted the housing association, who sent a locksmith round to get in through the front door. I followed the police officer inside and we went into one room after another, looking for Lenny.

We found him in his bedroom. It looked as if he had knelt down to change the station on a portable radio on the floor. Then something catastrophic must have happened and he had collapsed backwards, folding down onto his knees, his feet trapped under his body. He was dead. He had probably been dead for two or three days. He died alone, and no-one had found him for two or three days. He was 30 years old.

There was an initial inquest, as the police suspected that he might have taken an overdose. But I didn’t believe that, and the post mortem revealed that he had had an unsuspected heart defect, and had had a heart attack.

His support workers and I attended the interment. His father and sister and a few family members were there. There was no sign of his mother. No friends attended.

Why had Lenny’s life been so bereft and ultimately so sad? What had happened during his childhood that was so bad that he once ran out of the room when I merely started to talk to him about the idea of possibly talking about it at some point in the future? And had whatever happened to him made him how he was, suspicious, lacking in social skills, reluctant to make friends or trust anyone?

Did he ever have an emotionally unstable personality disorder, or did he actually have a psychotic illness that had not been diagnosed? Did the label of personality disorder stop people from looking further? His discharge from detention the first time certainly gave him the unfettered opportunity to develop a full-blown psychosis, as a Tribunal had decided he did not need treatment, and the CMHT had had to back off, for a while at least.

Undoubtedly, his eventual symptoms were text-book signs of paranoid schizophrenia, and these symptoms eventually resolved with the use of antipsychotic medication. And when he was free of psychotic symptoms, there were also no signs of emotionally unstable personality disorder. Would he have spent less time in hospital had he been started on that sort of medication in his teens? Would he have had more of a life before his heart defect eventually killed him?

I don’t have the answers to those questions. All I know now, is that Lenny lived, and then he died.

Tuesday, 19 July 2011

I’ve thought a lot about Lenny over the last few years since his death. I’ve thought about writing his story on this blog for a long time. I feel that I need write about him, since otherwise, Lenny and people like him tend to get forgotten, as if they had never existed. But Lenny did exist, and so this is his life story. This is too long for a single post, so Part 2 will follow in a few days.

I can’t really say much about his early life, as he always refused point blank to discuss anything about his childhood, and would become agitated and distressed if he was pushed about this. All I know is that his parents separated when he was 13. After his parents’ divorce, he lived with his mother.

Lenny first became a patient of psychiatric services at the age of 14, when he was assessed by the Child and Adolescent Mental Health Service (CAMHS). Was there a connection between his parents’ divorce and the beginning of his mental health problems? If so, it was not identified. They diagnosed him with depression, noting that there appeared to be an unhealthy relationship between him and his mother, but at the time no further treatment was offered.

When Lenny was 16 he was admitted to psychiatric hospital, again with a diagnosis of depression, and was followed up this time after discharge. When he reached the age of 17, he was transferred to adult mental health services. That was when I first met him. By now, he was living with his father, who had remarried, after his mother went off to “find herself” in some sort of therapeutic community. The main reason I was asked to see him was because things were becoming increasingly difficult at home, as he did not get on with his step-mother, and this was affecting his mood. I arranged for him to move into a hostel in Charwood.

Lenny lacked skills in making friends, and remained quite isolated within the hostel. He found it difficult to fill his days, but was reluctant to engage in activities that might improve his self confidence. He refused to have any therapy, and used to blow his benefit money on alcohol each week, and spend the next day or two drunk. During these times, he often also took fairly minor overdoses, which he would then tell everyone about, or would try and provoke other hostel residents.

At that time I was on the management committee of the hostel, and the committee members used to have regular fortnightly dinners with the residents. I came to know Lenny quite well, although he always remained suspicious of everyone, and never allowed anyone to get close to him in any way.

Over the 13 years I knew Lenny, I had to assess him under the MHA on a total of 8 occasions. Initially, these were following overdoses. The first two assessments did not result in an admission – there was no real suicidal intent, and hospital admission would not have achieved anything therapeutic.

This behaviour continued, but was generally tolerated by the hostel staff, the committee and the residents. It was simply what Lenny did.

One day, however, when he had been at the hostel for 3 years, and was approaching 21 years of age, he went to a day centre he sporadically attended armed with a large knife and threatened to kill himself in front of the staff and other service users. He was arrested by the police and I then conducted my third assessment under the MHA. This time I somewhat reluctantly concluded that I had no option but to detain him under Sec.3 for treatment.

He remained on the ward for several months, but would not engage in therapeutic activities, and resisted other treatment. But he remained a significant risk if he were discharged. For several years his main diagnosis had been that of depression, but his consultant at that time concluded that he had a personality disorder, and that the only suitable treatment was enforced psychotherapy in a secure unit. I was not sure about this – not that I did not think that he probably did have a borderline personality disorder, but my concern was whether it was either ethical or possible to engage someone in psychotherapy against their will. Nevertheless, funding for this was agreed, a suitable hospital was identified, and Lenny was transferred there.

Lenny hated it. He hated being forced to conform. He hated having to attend therapeutic groups. He hated having to attend sessions with clinical psychologists and occupational therapists. In fact, he hated everything and everybody. Although I had had no control over this transfer, he blamed me. He appealed against his detention.

The Tribunal was interesting. His Charwood psychiatrist presented a report and attended the Tribunal hearing. But he had made some errors in his report. He had stated that he could find no evidence of formal psychiatric disorder, but also stated that Lenny had a borderline personality disorder. Both the Tribunal and Lenny’s solicitor picked up on this. If Lenny did not have a mental disorder of a nature or degree sufficient to warrant his detention for treatment, then the Tribunal would have no option but to discharge him. So how did this statement accord with his diagnosis?

The psychiatrist tied himself in knots trying to justify the contradictory statements. But he was sinking without trace. The Tribunal were from the beginning sceptical about the idea of enforcing psychotherapy, and the inpatient psychiatrist was unable to state that this treatment was making any difference to Lenny’s mental state. So what justification could there be for continuing to detain him if treatment was not alleviating his problems? Lenny’s solicitor was pushing at an open door. The Tribunal discharged him, leaving just enough time to identify an address to discharge him to. Lenny stated that his sister, who lived in Charwood, would gladly offer him a place to live.

A week later, he moved in with his sister. I visited him at her home. He had used his new freedom to begin drinking again. His sister did not like this behaviour in front of her children. She wasn’t prepared to keep him.

There happened to be a vacancy at the hostel, so he returned there. He refused any further contact with the CMHT, although I continued to see him from my involvement with the hostel committee.

Something had changed about him. Although his sporadic alcohol abuse continued as before, he became even more suspicious and reclusive. For the next couple of years he remained at the hostel, where he started to make odd allegations about other residents, sometimes (usually when drunk) alleging that people were contaminating his food or his drink, or were trying to poison him.

To be continued

Next time: Lenny's incarceration in a secure unit for three years -- and eventual freedom.

Sunday, 10 July 2011

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About Me

I am an Approved Mental Health Professional working in a semi-rural area in England. I have practised under 3 Mental Health Acts, since as long ago as 1981, even before the 1983 Mental Health Act. Which makes me pretty ancient now.
This blog is designed to illuminate and explain the functions and dlimemmas of an AMHP within the Mental Health Act. It is intended to be of help to professionals and service users alike. I hope that it is both informative and entertaining.
I am also a freelance trainer, and a part time tutor on an AMHP course. I've appeared at conferences all over England and Wales. If you'd like to book me for your conference or training event just send me an email.